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Based on reviews of clinical record, manufacturer's instructions,hospital documents, and staff interviews, the hospital failed to provide and administer medication to 1 of 2 sample patients (45), in accordance with the orders of the physician and accepted standards of practice when the licensed nurse failed to provide a medication in a timely manner, resulting in two missed two doses. In addition, the nursing staff failed to provide the medication with meals as ordered by the physician and recommendations of the drug manufacturer.

Findings:

The medical record indicated Patient 45 was admitted to the hospital on 4/18/14 with diagnoses including diabetes, chronic kidney disease on dialysis (treatment that removes wastes in the blood done by healthy kidneys and hypertension (high blood pressure).

A review of the laboratory result done on 4/18/14 showed that Patient 45 had high levels of phosphorous of 7.2. (Normal 2.5 - 4.5 md/dl) Phosphorus is a mineral that makes up 1% of a person's total body weight. It is present in every cell of the body. Excessively high levels of phosphorus in the blood, can combine with calcium to form deposits in soft tissues such as muscle. High levels of phosphorus in blood only occur in people with severe kidney disease or severe dysfunction of their calcium regulation (Medlineplus medical encyclopedia).

On 4/19/14 at approximately 4 PM, the physician order indicated "Renagel 800 mg 3 po (oral) with meals, Renagel, is a medication to bind serum phosphorous in patients with chronic kidney disease on dialysis to prevent calcification of soft tissue and muscles. This medication was not given to the patient according to medical record review until 4/20/14 at approximately 10 AM. This delay resulted in two missed doses of the medication. According to the hospital's policy titled, "Patient Meal Service Schedule," breakfast starts at 7 AM, lunch at 11:30 AM and dinner at 5:30 PM. Based on this meal schedule, Patient 2 would have received two meals, since the medication was to have been taken with meals, this resulted in two missed doses at dinner time on April 19, 2014 and at breakfast time on April 20, 2014.

A review of the drug information provided by the hospital pharmacy showed that the medication "should be taken with meals." In an interview with the hospital's pharmacist on 4/25/14 at approximately 2 PM, in response to the missed doses, he stated that the hospital's policy was the pharmacist would review the first dose of every new medication prior to administration. He stated that the order was received late and therefore was not reviewed until the following day. This procedure resulted in two missed doses. A review of the policy titled, "Drug Therapy Monitoring (Monitoring the Effects if drugs on Patients)" showed that under certain conditions the staff may administer needed medication without prior pharmacist review. Neither the pharmacist nor the chief nursing officer during interviews on 4/25/14 and 5/08/14 showed that Renagel did not meet the criteria as indicated in the policy. The hospital did not provide additional policy on obtaining drugs when the pharmacy is closed which was referenced in the "Drug Therapy Monitoring (Monitoring the Effects if drugs on Patients) " policy.

In an interview with the ordering physician on 5/09/14 at approximately 4:25 PM, he stated that he does not recall being called by the nursing staff that the medication was not given as he had ordered it. He further stated that his expectation was that he would be informed if two doses of the medication were missed.

A review of the electronic medical record showed that the medication was not given with meals as ordered by the physician. The Medication Administration History Report showed that Patient 45 received the medication on 4/20/14 at 9:39 AM (two hours past meal time) and at 11:30 AM, 2 hours after the initial dose and at 4:54 PM about 36 minutes before scheduled meal time. The manufacturer instructions indicated "if you remember that you forgot to take a dose within 1 hour of a missed dose, take the missed dose. Otherwise skip the missed dose. " This pattern of giving medication after meals or before meals which is not ordered by the physician or manufacturer's directions is documented throughout her stay. Of the 15 opportunities, 6 were not administered appropriately. A review of the Medication Administration History Report showed the scheduled medication administration times were 0700, 1130 and 1700. Two of the three times did not match the scheduled meal times of 0730, 1130 and 1730. The scheduled medication administration times resulted in medications being incorrectly administered before meal time two of three times per day.

Based on review of clinical record, staff interviews, and review of hospital documents, the hospital failed to ensure that therapeutic diet was ordered by the physician responsible for the care of the patient when the nursing staff failed to clarify the incorrect diet order entered in the electronic medical record for 1 of 2 sample patients (45). This failure resulted in the potential of the restriction of nutrients that were not necessary or would make her condition worsent.

Finding:

The medical record indicated Patient 45 was admitted to the hospital on 4/18/14 with diagnoses including diabetes, chronic kidney disease and hypertension (high blood pressure). Her physician ordered diet on admission was 1800 ADA (American Diabetes Association) diet.

The nutrition assessment conducted on 4/22/14 showed the registered dietitian recommended that the physician consider adding Renal 80 gram protein diet and Nephrovite, a special vitamin for patients on dialysis. The clinical record showed on 4/23/14 the diet was changed to 80 gram protein, 2 gram, (no specific nutrient restriction) 1800 calorie ADA diet.

Clinical record review showed there was no documented evidence by nursing staff that the order was clarified as the 2 gram portion of the diet did not specify what nutrient the physician wanted to restrict to 2 grams. Possible choices of nutrients that could have been restricted were sodium, potassium and phosphorous. A review of the list of diet orders available in the hospital's electronic medical record showed the 2 gm sodium, 2 gram potassium diets and the renal dialysis diet which is a 2 gram sodium, 2 gram potassium, 80 gram protein diet were the only diets that had restrictions of "2 gram" and could have been ordered.

According to the hospital's system, the patient was served a 2 gram sodium, 2 gram potassium, 80 gram protein, 1800 calorie diet. The hospital failed to ensure diet served was what the physician intended to order.

Based on review of clinical record, manufacturer's instructions, staff interviews and review of hospital documents, the hospital failed to ensure that the nutritional needs of 1 of 2 sampled patients (Patient 45) was met when the licensed nurses failed to provide a nutritional supplement as ordered by the physician. Patient 45 did not receive the supplement to replace the nutrients lost during dialysis for seven days, and was discharged without receiving the supplement. The failure of the hospital staff to carry out a physician's order resulted in Patient 45 not receiving additional or replacement nutrition ordered by her physician.


Findings:

The medical record indicated Patient 45 was admitted to the hospital on 4/18/14 with diagnoses including diabetes, chronic kidney disease and hypertension (high blood pressure). Her physician ordered diet on admission was 1800 ADA (American Diabetes Association) diet. On 4/19/14, her physician ordered Nepro (a nutrition supplement for patients on dialysis) one can three times a day and Renagel a medication to bind phosphorous.

Clinical record review showed that Patient 45 was on dialysis three days a week prior to her admission. She received dialysis twice during her admission. According to the manufacturer's information, Nepro is designed for people on dialysis to help restore protein and other nutrients lost during dialysis treatment. A can of Nepro contains approximately 425 calories and 19 grams of protein. The three cans would have provided a total of 1272 calories and 57 grams of protein per day and replaced many of the nutrients she would have lost during dialysis.

Clinical record review conducted on 4/25/14 showed Patient 45 never received the Nepro because the physician's order was not carried out. A review of the hospital's policy titled Chart Check, 12 hour indicated that the registered nurse is to assure that all physician orders are transcribed and carried out completely and accurately in the patient's EHR (Electronic Health Record).

In an interview with the Director of Quality and Risk Management 1 on 4/25/14 at approximately 1:50 PM, she acknowledged that there was no documented evidence that Patient 45 was given Nepro. A review of the clinical record indicated that two licensed nurses were responsible for ensuring that the order was carried out. Neither was available for interview because they worked the night shift.

This is the repeat deficiency from the sample validation survey on 12/12/13.

Based on review of clinical record, hospital document and staff interview, the hospital failed to ensure that 1 of 2 sample patients, Patient 45 received in-patient education for self-care care after dialysis treatment. Patient 45 was not provided education after the dialysis treatments because she was a Spanish speaking only. This failure resulted in incresed risk of Patient 45 not being to recognize or report side effects of treatment timely and therefore worsen her medical condition.

Finding:

The medical indicated Patient 45 was admitted to the hospital on 4/18/14 with diagnoses including diabetes, chronic kidney disease on dialysis and hypertension (high blood pressure).

The medical record indicated during admission, Patient 45 received dialysis treatments from a company contracted by the hospital. A review of the Dialysis Treatment Record dated 4/19/14 and 4/24/14 showed that post dialysis patient education was not provided. On 4/19/14, the Dialysis Treatment Record indicated "not receivable at this time." The reason was not indicated. On 4/24/14, the Patient Education area of the Dialysis Treatment Record indicated the following information:
"not receivable- Spanish speaking only unable to understand English."


The hospital patient population is over 90% Latino and mostly Spanish speaking. A review of the contract with the dialysis company showed that the terms of the contract required "company staff must be able to speak, write and read the English language sufficiently to communicate with patients and other staff ... " The terms of the contract did not put into consideration the fact that the population being served mainly spoke another language other than English.
The hospital failed to ensure that Patient 45 was provided in-patient education due to inability of contracted staff to speak the language spoken by the patient.

In an interview with the chief nursing officer on 4/25/14 at approximately 2:30 PM, she stated she was not aware that the dialysis staff had documented that they were not able to provide education because Patient 45 was Spanish speaking.